Vulnerability Index & Service Prioritization Decision Assistance Tool (VI-SPDAT)

Prescreen for Families

GENERAL INFORMATION/CONSENT

Interviewer’s Name / Agency
 TEAM  STAFF  VOLUNTEER
Date / Time / Location
HEAD OF HOUSEHOLD 1
In what language do you feel best able to express yourself?
First Name / Last Name
Nickname / Social Security Number
How old are you? / What’s your date of birth? / Has Consented to Participate
 YES  NO
Gender:
 Female
 Male
 Transgendered
 Refused / Which of the following best describes your race:
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Don’t Know
Refused / Which of the following best describes your ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Don’t Know
Refused
Have you served in the US Military?
 Yes
 No
 Refused / IF THEY SERVED IN THE MILITARY:
 World War II
 Korean War
 Vietnam War
Persian Gulf War (Operation Desert Storm)
 Afghanistan (Operation Enduring Freedom)
 Iraq (Operation Iraqi Freedom)
 Iraq (Operation New Dawn)
Other Peace-keeping Operations or Military Interventions
 Refused / IF THEY SERVED IN THE MILITARY:
 Honorable Other than Honorable
 Bad Conduct  Dishonorable  Refused
HEAD OF HOUSEHOLD 2 (when applicable)
In what language do you feel best able to express yourself?
First Name / Last Name
Nickname / Social Security Number
How old are you? / What’s your date of birth? / Has Consented to Participate
 YES  NO
Gender:
 Female
 Male
 Transgendered
 Refused / Which of the following best describes your race:
White
Black or African American
Asian
American Indian or Alaska Native
Native Hawaiian or Pacific Islander
Don’t Know
Refused / Which of the following best describes your ethnicity:
Hispanic or Latino
Non-Hispanic or Non-Latino
Don’t Know
Refused
Have you served in the US Military?
 Yes
 No
 Refused / IF THEY SERVED IN THE MILITARY:
 World War II
 Korean War
 Vietnam War
Persian Gulf War (Operation Desert Storm)
 Afghanistan (Operation Enduring Freedom)
 Iraq (Operation Iraqi Freedom)
 Iraq (Operation New Dawn)
Other Peace-keeping Operations or Military Interventions
 Refused / IF THEY SERVED IN THE MILITARY:
 Honorable Other than Honorable
 Bad Conduct  Dishonorable  Refused
CHILDREN
Total number of children under the age of 18 that are currently with the head(s) of household / RESPONSE / REFUSED

How many children under the age of 18 are not currently with your family, but you have reason to believe they will be joining you when you get housed? / RESPONSE / REFUSED

Last Name / First Name / Race / Ethnicity / Gender / How old? / Date of Birth
Only ask the following question when there is at least one female head of household, and/or if there is at least one female child 13 years of age or older:
Is any member of the family currently pregnant? / YES
 / NO
 / REFUSED

A. HISTORY OF HOUSING & HOMELESSNESS

QUESTIONS
RESPONSE / REFUSED
1. What is the total length of time you and your family have lived on the streets or in shelters? / 
2. In the past three years, how many times have you and your family been housed and then homeless again? / 

B. RISKS

SCRIPT: I am going to ask some questions about all the times you and other members of your family have had interactions with health and emergency services. If you need any help figuring out when six months ago was, just let me know.

QUESTIONS
RESPONSE / REFUSED
3. In the past six months, how many times have you and/or members of your family been to the emergency department/room? / 
4. In the past six months, how many times have you and/or members of your family had an interaction with the police? / 
5. In the past six months, how many times have you and/or members of your family been taken to the hospital in an ambulance? / 
6. In the past six months, how many times have you and/or members of your family used a crisis service, including distress centers or suicide prevention hotlines? / 
7. In the past six months, how many times have you and/or members of your family been hospitalized as an in-patient, including hospitalizations in a mental health hospital? / 
8. Have you or any family member been attacked or beaten up since becoming homeless? /  /  / 
9. Have you or any family member threatened to or tried to harm themselves or anyone else in the last year? /  /  / 
10. Do you or any member of the family have any legal stuff going on right now that may result in being locked up or having to pay fines? /  /  / 
11. Does anybody force or trick you or any member of the family to do things that they do not want to do? /  /  / 
12. Do you or any family member ever do things that may be considered to be risky like exchange sex for money, run drugs for someone, have unprotected sex with someone you don’t really know, share a needle, or anything like that? /  /  / 
13. I am going to read types of places people sleep. Please tell me which one that you and your family sleep at most often. (Check only one.) / Shelter
Street, Sidewalk or Doorway
Car, Van or RV
Bus or Subway
Beach, Riverbed or Park
Other (SPECIFY):

C. SOCIALIZATION & DAILY FUNCTIONS

QUESTIONS
YES / NO / REFUSED
14. Is there anybody that thinks you or any family member owes them money? /  /  / 
15. Does the family have any money coming in on a regular basis, like through a job or government benefit or even working under the table, binning or bottle collecting, sex work, odd jobs, day labor, or anything like that? /  /  / 
16. Does your family have enough money to meet all expenses on a monthly basis? /  /  / 
17. Do you and each member of the family have planned activities each day other than just surviving that bring happiness and fulfillment? /  /  / 
18. Do you or any member of the family have any friends, family or other people in your life out of convenience or necessity, but you do not like their company? /  /  / 
19. Do any friends, family or other people in you or your family’s life ever take your money, borrow cigarettes, use your drugs, drink your alcohol, or get you to do things you really don’t want to do? /  /  / 
20. Surveyor, do you detect signs of poor hygiene or daily living skills of any family member? /  / 

D. WELLNESS

QUESTIONS
21. Where do you and other family members usually go for healthcare when you’re not feeling well? /  Hospital
Clinic
VA
 Other (specify)
Does not go for care
Do you or any family member have now, ever had, or had a healthcare provider ever told you that you have any of the following medical conditions: / YES / NO / REFUSED
22. Kidney disease/End Stage Renal Disease or Dialysis /  /  / 
23. History of frostbite, Hypothermia, or Immersion Foot /  /  / 
24. Liver disease, Cirrhosis, or End-Stage Liver Disease /  /  / 
25. HIV+/AIDS /  /  / 
26. History of Heat Stroke/Heat Exhaustion /  /  / 
27. Heart disease, Arrhythmia, or Irregular Heartbeat /  /  / 
28. Emphysema /  /  / 
29. Diabetes /  /  / 
30. Asthma /  /  / 
31. Cancer /  /  / 
32. Hepatitis C /  /  / 
33. Tuberculosis /  /  / 
OBSERVATION ONLY – DO NOT ASK:
34. Surveyor, do you observe signs or symptoms of a serious health condition? /  / 
YES / NO / REFUSED
35. Have you or any member of the family ever had problematic drug or alcohol use, abused drugs or alcohol, or told you do? /  /  / 
36. Have you or any family member consumed alcohol and/or drugs almost every day or every day for the past month? /  /  / 
37. Have you or any family member ever used injection drugs or shots in the last six months? /  /  / 
38. Have you or any family member ever been treated for drug or alcohol problems and returned to drinking or using drugs? /  /  / 
39. Have you or any family member used non-beverage alcohol like cough syrup, mouthwash, rubbing alcohol, cooking wine, or anything like that in the past six months? /  /  / 
40. Have you or any family member blacked out because of alcohol or drug use in the past month? /  /  / 
41. Has any family member under the legal drinking age consumed alcohol four or more times in the last month or used drugs at any point in time during the last month – including marijuana or prescription pills to get high? /  /  / 
OBSERVATION ONLY – DO NOT ASK:
42. Surveyor, do you observe signs or symptoms or problematic alcohol or drug use? /  / 
YES / NO / REFUSED
43. Have you or any family member ever been taken to a hospital against their will for a mental health reason? /  /  / 
44. Have you or any family member ever gone to the emergency room because they weren’t feeling 100% well emotionally or because of their nerves? /  /  / 
45. Have your or any member of your family spoken with a psychiatrist, psychologist or other mental health professional in the last six months because of mental health – whether that was voluntary or because someone insisted that it be done? /  /  / 
46. Have your or any member of your family had a serious brain injury or head trauma? /  /  / 
47. Have you or any member of your family ever been told they have a learning disability or developmental disability? /  /  / 
48. Do you or any member of your family have any problems concentrating and/or remembering things? /  /  / 
OBSERVATION ONLY – DO NOT ASK:
49. Surveyor, do you detect signs or symptoms of severe, persistent mental illness or severely compromised cognitive functioning? /  / 
ASK THIS QUESTION ONLY WHEN THERE WAS Substance Use AND Mental Health, and Medical Conditions
50. You indicated in your responses that there is a medical condition, experience with mental health services and experience with substance use. Is that the same member of the family in all of those instances?
YES / NO / REFUSED
51. Have you or any member of the family had any medicines prescribed by a doctor that were not take, sold, stolen, misplaced, or where the prescriptions were never filled? /  /  / 
YES / NO / REFUSED
52. Yes or No – Have you or any member of your family experienced any emotional, physical, psychological, sexual or other type of abuse or trauma which help was not sought for, and/or which has caused your homelessness? /  /  / 

E. FAMILY UNIT

QUESTIONS
YES / NO / REFUSED
53. Do any of your children spend two or more hours per day when you don’t know where they are? /  /  / 
54. On most days, do any children do tasks that adults would normally do like preparing meals, getting other children ready for bedtime, shopping, cleaning the apartment, or anything like that? /  /  / 
RESPONSE / REFUSED
55. What is the total number of times adults in the family have changed in the family over the past year because of things like new relationships or a breakdown in the relationship, prison, military deployment, or anything like that? / 
56. What is the total number of times that children have been separated from the family or returned to the family over the past year?
YES / NO / REFUSED
57. Are there any school-aged children that are not enrolled in school or missing more days of school than they are attending? /  /  / 
58. Right now or at any point in the last six months have any of your children been separated from you to live with a family member or friend? /  /  / 
YES / NO / REFUSED
59. Has there been any involvement with any member of your family and child protective services in the last six months – even if it was resolved? /  /  / 
60. Have you had anything in family court over the past six months or anything currently being considered in family court? /  /  / 

Finally I’d like to ask you some questions to help us better understand homelessness and improve housing and support services.

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Vulnerability Index & Service Prioritization Decision Assistance Tool (VI-SPDAT)

Prescreen for Families

What is your citizenship status? /  Citizen  Legal Resident  Undocumented  Refused
Where did you live prior to becoming homeless? /  This city
 This region
 Other part of the State
 Somewhere else (specify)______
Have you ever been in foster care? /  Yes  No  Refused
Have you ever been in jail? /  Yes  No  Refused
Have you ever been in prison? /  Yes  No  Refused
Do you or any member of the family have a permanent physical disability that limits mobility? [i.e., wheelchair, amputation, unable to climb stairs]? /  Yes  No  Refused
What kind of health insurance do you have, if any? (check all that apply) /  Medicaid  Medicare  VA  Private Insurance
 None  Other (specify): ______
On a regular day, where is it easiest to find you and what time of day is easiest to do so?
Is there a phone number and/or email where someone can get in touch with you or leave you a message?
Ok, now I’d like to take your picture. May I do so? /  Yes  No  Refused

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